Incisional Hernia

Presentation:

• Bulge at the surgery site
• Dragging pain (esp in obese, pregnant ladies)
• Relieved by abdominal binding
• Complications: obstruction or strangulation
• Don’t insist on feeling the size of defect (esp if non-reducible), why? very painful and it won’t change anything in the management in the clinic -> measure it in the OR

 

Patient-related factors:

• Age: old age is related to weak fascia -> improper healing
• Gender is controversial
• Poor glycemic control:
  • Diabetes is not an independent risk factor of incisional hernia
  • Most important pre-op prep to prevent surgical-site infections is strict glycemic control (which is measure by HgbA1C) (more important than antibiotics)
• Surgical site infection is the single most imp factor of developing incisional hernia!
• Collagen vascular diseases: Ehler-Danlos syndrome, Marfan syndrome, SLE, vasculitis
• Smoking -> causes degradation of collage and destroys good fascia
  • AAA -where smoking affects the content of collage in a vessel wall- surgery through a midline laparotomy carries a higher risk of hernia
• Immunodeficiency: congenital, acquired, immunosuppressive therapy, steroid, chemo, radiation
• Malnutrition: can be general or specific (zinc or vitamin C deficiency), obesity (a form of malnutrition)
• Increased intra-abdominal pressure: due to;
  • Obesity
  • Pregnancy
  • Ascites: hepatic (portal HTN), cardiac (right HF), renal (nephrotic), intestinal (protein-losing enteropathy), peritoneal dialysis, carcinomatosis
  • Intra-abdominal tumors which attain large caner: ovarian, endometrial fibroids, desmoid tumors, GEST, lymphomas, cystic lesions of pancreas, mesenteric cyst
  • Retroperitoneal tumors or sarcoma
  • Chronic cough
  • Constipation
  • BPH causing chronic obstructive urinary symptoms

 

Surgery related factors:

• Types of incisions
  • Midline laparotomy is the worst when it comes to risk of incisional hernia but the best for exposure

• Same incision, different procedure:
  • Midline laparotomy for splenectomy -> clean
  • Midline laparotomy for gastrectomy -> clean-contaminated
  • Midline laparotomy for colectomy in a prepped colon -> contaminated
  • Midline laparotomy for colectomy in an un-prepped colon -> dirty

• Same incision, same procedure, elective vs emergency:
  • Left hemicolectomy on emergency -> higher risk of herniation compared to elective left hemicolectomy

• Closure:
  • No difference in the risk of hernia between interrupted vs continuous closure -> so for convenience, we always close w\ continuous
  • What’s important is taking good fascia, good distance, no tension (which causes recurrence and strangulation of tissue)

• Type of suture:
  • No difference between resorbable vs non-resorbable -> so use appropriately resorbable sutures (which gives enough time for fascia to heal and prevent hernia)

 

CASE: 2 patients, one w\ 10-cm defect, the other w\ 2-cm defect. Which one you’ll do first?  The smaller one -> risk of bowel entrapments, strangulation, and irreducibility

CASE: Child-Pugh C cirrhotic pt, bed bound, very little activity, w\ wide neck hernia. Would you repair it? No, b\c he is a poor surgical candidate and the hernia is not “bothering” him

 

Treatment:

• Surgical repair for active pts with symptoms
  • Mesh vs no mesh?
    • Primary hernia -> depends on the size:
      • Big primary hernia -> mesh
      • Small primary hernia -> no mesh
    • Incisional hernia -> always use mesh!
    • Mesh doesn’t increase the risk of infection, but makes infection easier to develop .. 🙂
    • Always give pre-op abx if you’re contemplating putting a mesh
  • Open vs laparoscopic?
    • Small hernia (1-2 cm) -> open
    • ≥ 3 cm hernia -> laparoscopic
    • Giant hernia (> 15 cm, should be taken in the light of torso size, or > 50% of abdominal content outside) -> open
  • Don’t advise pt to use abdominal banding if they are a surgical candidate, why?
    1. Pressure on the skin -> skin abrasions and infection -> high risk of surgical-site infection
    2. Disuse atrophy

 

Lumbar hernia 

• Difficult to treat; no fascia + between two bony prominences -> no place to fixate mesh

Epigastric hernia:

• Anywhere in the midline (linea alba = extra-peritoneal fat -> no true sac, only breach in muscle fibers), from xiphoid to 2-cm above umbilicus, usually small and very painful

 

---

Download the PDF version: here

---

References:

• Dr Alabeidi’s lecture and clinical notes